ËÄ»¢Ó°ÊÓ

*Workers’ Compensation Insurance Carrier*
P.O. Box 13777
Austin, Texas 78711

Phone: (512) 475-1440
Toll Free: (877) 445-0006
Fax: (512) 370-9025

Forms

Submit completed forms to the Human Resources claims coordinator.

• Supervisor's Investigation of Employee's Accident/Incident (PDF)
• Employee's Report of Injury (PDF)
• Authorization for Release of Information (PDF)
• Witness Statement (PDF)
• Employee's Election Regarding Utilization of Sick and Annual Leave (PDF)
• Return to Work Status Form (PDF)